============================================================================= Run Date: DEC 17, 2015 Designation: EAS*1*107 Package : EAS - ENROLLMENT APPLICATION SYSTEM Priority: Mandatory Version : 1 SEQ #104 Status: Released Compliance Date: JAN 01, 2016 ============================================================================= Associated patches: (v)EAS*1*103 <<= must be installed BEFORE `EAS*1*107' Subject: UPDATE PRINT 1010EZ/1010EZR TO NEW FORMAT Category: - Routine - Enhancement (Mandatory) - Informational Description: ============ ***************************************************************************** Note: This patch is being released in support of the Enrollment Customer Enhancements (ECE) and Enrollment System Enhancements (ESE) projects and the Enrollment System (ES) 3.11 release. EAS*1*107 (Enrollment Application System) is being released with DG*5.3*865 (Registration) and EAS*1.0*111 (Enrollment Application System) in host file DG_53_P865.KID. It is imperative that this patch be installed no later than the compliance date. Your understanding and support is appreciated. ***************************************************************************** The Health Eligibility Center (HEC) requested modifications to the VistA Registration, Enrollment and Eligibility (VistA REE) software to modify the current versions of the Print 1010EZ and 1010EZR forms to adhere to the Feb 2011 format version of the forms. The following changes were made to the 10-10EZ form: ---------------------------------------------------- Header Page 1 - Remove "Expiration Date 6/30/2007" SECTION I - GENERAL INFORMATION Block 2005 Form 2011 Form 5 WHAT IS YOUR RACE? Moved to Block 6 6 ARE YOU SPANISH, HISPANIC, OR LATINO? Moved to Block 5 8 CLAIM NUMBER Changed to "VA CLAIM NUMBER" 11H PAGER NUMBER Deleted 12 TYPE OF BENEFIT(S) APPLIED FOR Changed to "TYPE OF BENEFIT(S) APPLYING FOR" 13 IF APPLYING FOR HEALTH SERVICES OR Changed to "WHICH VA MEDICAL ENROLLMENT, WHICH VA MEDICAL CENTER CENTER OR OUTPATIENT CLINIC OR OUTPATIENT CLINIC DO YOU PREFER? DO YOU PREFER?" 14 HAVE YOU BEEN SEEN AT A VA HEALTH Deleted CARE FACILITY? 15 DO YOU WANT AN APPOINTMENT WITH A Moved to Block 14 VA DOCTOR OR PROVIDER AS SOON AS ONE BECOMES AVAILABLE? 16 CURRENT MARITAL STATUS Moved to Block 15 17 NAME, ADDRESS AND RELATIONSHIP OF Moved to Block 16 NEXT OF KIN 17A NEXT OF KIN'S HOME TELEPHONE NUMBER Moved to Block 16A 17B NEXT OF KIN'S WORK TELEPHONE NUMBER Moved to Block 16B 18 NAME, ADDRESS AND RELATIONSHIP OF Moved to Block 17 EMERGENCY CONTACT 18A EMERGENCY CONTACT'S HOME TELEPHONE Moved to Block 17A NUMBER 18A EMERGENCY CONTACT'S WORK TELEPHONE Moved to Block 17B NUMBER 19 INDIVIDUAL TO RECEIVE POSSESSION OF Deleted YOUR PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE TIME OF DEATH SECTION II - INSURANCE INFORMATION Block 2005 Form 2011 Form 1 ARE YOU COVERED BY HEALTH INSURANCE? Deleted 2 HEALTH INSURANCE COMPANY NAME, Moved to Block 1 ADDRESS AND TELEPHONE NUMBER 3 NAME OF POLICY HOLDER Moved to Block 2 4 POLICY NUMBER Moved to Block 3 5 GROUP CODE Moved to Block 4 6 ARE YOU ELIGIBLE FOR MEDICAID? Moved to Block 5 5A Added "EFFECTIVE DATE" 7 ARE YOU ENROLLED IN MEDICARE HOSPITAL Moved to Block 6 INSURANCE PART A? 7A EFFECTIVE DATE Moved to Block 6A 8 ARE YOU ENROLLED IN MEDICARE HOSPITAL Moved to Block 7 INSURANCE PART B? 8A EFFECTIVE DATE Moved to Block 7A 9 NAME EXACTLY AS IT APPEARS ON YOUR Moved to Block 8 MEDICARE CARD 10 MEDICARE CLAIM NUMBER Moved to Block 9 11 IS NEED FOR CARE DUE TO ON THE JOB Deleted INJURY? 12 IS NEED FOR CARE DUE TO ACCIDENT? Deleted SECTION IV - MILITARY SERVICE INFORMATION Block 2005 Form 2011 Form 2C DO YOU HAVE A VA SERVICE-CONNECTED Deleted RATING? 2C1 IF YES, WHAT IS YOUR RATED PERCENTAGE? Deleted 2D DID YOU SERVE IN COMBAT AFTER Moved to 2C 11/11/1998? 2E WAS YOUR DISCHARGE FROM MILITARY FOR Moved to 2D A DISABILITY INCURRED OR AGGRAVATED IN THE LINE OF DUTY? 2E1 ARE YOU RECEIVING DISABILITY Moved to 2D1 RETIREMENT PAY INSTEAD OF VA COMPENSATION? 2F DO YOU NEED CARE OF CONDITIONS Moved to 2E and changed to POTENTIALLY RELATED TO SERVICE IN "DID YOU SERVE IN SW ASIA SOUTHWEST ASIA? DURING THE GULF WAR BETWEEN AUGUST 2,1990 AND NOVEMBER 11, 1998?" 2G WERE YOU EXPOSED TO AGENT ORANGE Moved to 2F and changed to WHILE SERVING IN VIETNAM? "DID YOU SERVE IN VIETNAM BETWEEN JANUARY 9, 1962 AND MAY 7, 1975?" 2H WERE YOU EXPOSED TO RADIATION WHILE Moved to 2G IN THE MILITARY? 2I DID YOU RECEIVE NOSE & THROAT RADIUM Moved to 2H TREATMENTS WHILE IN THE MILITARY? 2J DO YOU HAVE A SPINAL CORD INJURY? Moved to 2I SECTION V - PAPERWORK REDUCTION ACT AND Moved to Section X PRIVACY ACT INFORMATION Second paragraph, fifth sentence changed to: "Providing the requested information is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits." SECTION VI - FINANCIAL DISCLOSURE Moved to Section V Wording changed to: Disclosure allows VA to accurately determine whether certain Veterans will be charged copays for care and medications, their eligibility for other services and enrollment priority. Veterans are not required to disclose their financial information; however, VA is not currently enrolling new applicants who decline to provide their financial information unless they have other qualifying eligibility factors. Recent Combat Veterans are eligible for enrollment without disclosing their financial information but like other Veterans may provide it to establish their eligibility for travel assistance, cost-free medication and/or medical care for services unrelated to military experience. ___ NO, I DO NOT WISH TO PROVIDE INFORMATION IN SECTIONS VI THROUGH IX. I understand that VA is not enrolling new applicants who do not provide this information and who do not have other qualifying eligibility factors [i.e.,a former Prisoner of War; in receipt of a Purple Heart; a recently discharged Combat Veteran (e.g.,OEF/OIF/OND who were discharged within the past 5 years); discharged for a disability incurred or aggravated in the line of duty; receiving VA service-connected disability compensation; receiving VA pension; or in receipt of Medicaid benefits.] (Sign and date the form in Section XII.) ___ YES, I WILL PROVIDE MY HOUSEHOLD FINANCIAL INFORMATION FOR LAST CALENDAR YEAR. Complete applicable sections VI through IX. (Sign and date the form in Section XII.) SECTION VII - DEPENDENT INFORMATION Moved to Section VI Block 2005 Form 2011 Form 1A SPOUSE'S MAIDEN NAME Changed to "SPOUSE'S MAIDEN NAME OR OTHER NAMES USED" 2E WAS CHILD PREMANENTLY AND TOTALLY Corrected spelling to DISABLED BEFORE THE AGE OF 18? "PERMANENTLY" 3 IF YOUR SPOUSE OR DEPENDENT CHILD DID Changed to "IF YOUR SPOUSE OR NOT LIVE WITH YOU LAST YEAR, ENTER DEPENDENT CHILD DID NOT LIVE THE AMOUNT YOU CONTRIBUTED TO THEIR WITH YOU LAST YEAR, DID YOU SUPPORT PROVIDE SUPPORT?" SECTION VIII - PREVIOUS CALENDAR YEAR GROSS Moved to Section VII ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN SECTION IX - PREVIOUS CALENDAR YEAR DEDUCTIBLE Moved to Section VIII EXPENSES Block 2005 Form 2011 Form 2 (Also enter spouse or child's Changed to "(Also enter information in Section VII.) spouse or child's information in Section VI.)" SECTION XI - CONSENT TO COPAYMENTS Changed to "SECTION XI - CONSENT TO COPAYS" Wording changed to: "By signing this application you are agreeing to pay the applicable VA copays for treatment or services of your NSC conditions as required by law." SECTION XII - ASSIGNMENT OF BENEFITS Wording changed to: "I understand that pursuant to 38 U.S.C. section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to recover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in excess of the cost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessary and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize the VA to disclose, to my attorney and to any third party or administrative agency who may be responsible for payment of the cost of medical services provided to me, information from my medical records as necessary to verify my claim. Further, I hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim." Footer - All pages VA FORM 10-10EZ FEB 2005 Changed to "VA FORM 10-10EZ FEB 2011" The following changes were made to the 10-10EZR form: ----------------------------------------------------- SECTION I - GENERAL INFORMATION Block 2005 Form 2011 Form 6 CURRENT MARITAL STATUS Moved to Block 7 7 PERMANENT ADDRESS Moved to Block 6 7A CITY Moved to Block 6A 7B STATE Moved to Block 6B 7C ZIP Moved to Block 6C 7D COUNTY Moved to Block 6D 7E HOME TELEPHONE NUMBER Moved to Block 6E 7F E-MAIL ADDRESS Moved to Block 6F 7G CELLULAR TELEPHONE NUMBER Moved to Block 6G 7H PAGER NUMBER Deleted 10 INDIVIDUAL TO RECEIVE POSSESSION OF YOUR Deleted PERSONAL PROPERTY LEFT ON PREMISES UNDER VA CONTROL AFTER YOUR DEPARTURE OR AT THE TIME OF DEATH. SECTION IV - PAPERWORK REDUCTION ACT AND PRIVACY Moved to Section IX ACT INFORMATION Second paragraph, fifth sentence changed to: "Providing the requested information is voluntary, but if any or all of the requested information is not provided, it may delay or result in denial of your request for health care benefits." SECTION V - FINANCIAL DISCLOSURE Moved to Section IV Wording changed to: "Disclosure allows VA to accurately determine whether certain Veterans will be charged copays for care and medications, their eligibility for other services and enrollment priority. Veterans are not required to disclose their financial information. Recent Combat Veterans (e.g., OEF/OIF/OND) like other Veterans may answer YES in Section IV and complete Sections V-VIII to have their priority for enrollment and financial eligibility for travel assistance, cost-free medications and/or medical care for services unrelated to military experience. ___ NO, I DO NOT WISH TO PROVIDE FINANCIAL INFORMATION IN SECTIONS V THROUGH VIII. If I am enrolled, I agree to pay applicable VA copayments. Sign and date the form in Section XI. ___ YES, I WILL PROVIDE MY HOUSEHOLD FINANCIAL INFORMATION FOR LAST CALENDAR YEAR. Complete applicable Sections V through VIII. Sign and date the form in Section XI." SECTION VI - DEPENDENT INFORMATION Moved to Section V Block 2005 Form 2011 Form 3 IF YOUR SPOUSE OR DEPENDENT CHILD DID Changed to "IF YOUR SPOUSE NOT LIVE WITH YOU LAST YEAR, ENTER THE OR DEPENDENT CHILD DID NOT AMOUNT YOU CONTRIBUTED TO THEIR SUPPORT LIVE WITH YOU LAST YEAR, DID YOU PROVIDE SUPPORT?" SECTION VIII - PREVIOUS CALENDAR YEAR Moved to Section VII DEDUCTIBLE EXPENSES SECTION IX - PREVIOUS CALENDAR YEAR NET WORTH Moved to Section VIII SECTION X - CONSENT TO COPAYMENTS Wording changed to: "By signing this application you are agreeing to pay the applicable VA copays for treatment or services for your NSC conditions as required by law." SECTION XI - ASSIGNMENT OF BENEFITS Wording changed to: "I understand that pursuant to 38 U.S.C. Section 1729 and 42 U.S.C. 2651, the Department of Veterans Affairs (VA) is authorized to recover or collect from my health plan (HP) or any other legally responsible third party for the reasonable charges of nonservice-connected VA medical care or services furnished or provided to me. I hereby authorize payment directly to VA from any HP under which I am covered (including coverage provided under my spouse's HP) that is responsible for payment of the charges for my medical care, including benefits otherwise payable to me or my spouse. Furthermore, I hereby assign to the VA any claim I may have against any person or entity who is or may be legally responsible for the payment of the cost of medical services provided to me by the VA. I understand that this assignment shall not limit or prejudice my right to recover for my own benefit any amount in excess of the cost of medical services provided to me by the VA or any other amount to which I may be entitled. I hereby appoint the Attorney General of the United States and the Secretary of Veterans' Affairs and their designees as my Attorneys-in-fact to take all necessary and appropriate actions in order to recover and receive all or part of the amount herein assigned. I hereby authorize the VA to disclose to my attorney and to any third party or administrative agency who may be responsible for payment of the cost of medical services provided to me, information from my medical records as necessary to verify my claim. Further, I hereby authorize any such third party or administrative agency to disclose to the VA any information regarding my claim." Footer - All pages VA FORM 10-10EZR FEB 2005 Changed to "VA FORM 10-10EZR FEB 2011" Patch Components: ================= Files & Fields Associated: -------------------------- N/A Forms Associated: ----------------- N/A Mail Groups Associated: ----------------------- N/A Options Associated: ------------------- N/A Protocols Associated: --------------------- N/A Security Keys Associated: ------------------------- N/A Templates Associated: --------------------- The following is a list of templates included in this patch: Template Name Type File Name (Number) ------------- ---- ------------------ N/A New Service Request (NSRs): --------------------------- N/A Patient Safety Issues (PSIs): ----------------------------- N/A Remedy Ticket(s) & Overview: ---------------------------- N/A Test Sites: ----------- West Texas VA Health Care System, Big Spring, TX Fargo VA Health Care System, Fargo, ND Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI VA Pittsburgh Healthcare System, Pittsburgh, PATBD Documentation Retrieval: ======================== Updated documentation describing the new functionality introduced by this patch is available. The preferred method is to FTP the files from ftp://download.vista.domain.ext/. This transmits the files from the first available FTP server. Sites may also elect to retrieve software directly from a specific server as follows: Albany ftp.domain.ext Hines ftp.domain.ext Salt Lake City ftp.domain.ext The documentation will be in the form of Adobe Acrobat files. The following files should be downloaded in the binary FTP mode. Title File Name FTP Mode ----------------------------------------------------------------------- Enrollment Application System EAS_1_107_UM.PDF Binary User Manual Documentation can also be found on the VA Software Documentation Library at: http://www.domain.ext/vdl/ Patch Installation: =================== Installation Instructions: -------------------------- Please see the DG*5.3*865 Patch Description for installation instructions. Routine Information: ==================== The second line of each of these routines now looks like: ;;1.0;ENROLLMENT APPLICATION SYSTEM;**[Patch List]**;Mar 15, 2001;Build 32 The checksums below are new checksums, and can be checked with CHECK1^XTSUMBLD. Routine Name: EASEZP61 Before: B30387154 After: B36064376 **51,60,70,107** Routine Name: EASEZP62 Before: B63766210 After: B62742191 **51,60,70,107** Routine Name: EASEZP63 Before: B55264854 After: B17289170 **51,60,57,107** Routine Name: EASEZP64 Before: B28984285 After: B67534937 **60,57,70,107** Routine Name: EASEZP6F Before: B15092600 After: B14707219 **51,60,57,107** Routine Name: EASEZP6I Before: B2792780 After: B2999167 **51,60,107** Routine Name: EASEZP6U Before: B29983306 After: B29982956 **51,60,57,70,107** Routine Name: EASEZPDU Before: B41165544 After: B41360578 **57,70,107** Routine Name: EASEZPU3 Before: B24284626 After: B25454503 **57,107** Routine Name: EASEZPVI Before: B20529992 After: B21671020 **57,70,103,107** Routine Name: EASEZRP1 Before: B38490607 After: B36453210 **57,70,107** Routine Name: EASEZRP2 Before: B74192279 After: B76633535 **57,107** Routine Name: EASEZRP3 Before: B28501959 After: B39915034 **57,70,107** Routine Name: EASEZRPF Before: B15944209 After: B15520164 **57,107** Routine Name: EASEZRPU Before: B46765829 After: B49046361 **57,70,107** Routine Name: EASEZU1 Before: B15904642 After: B16968808 **107** Routine list of preceding patches: 103 ============================================================================= User Information: Hold Date : DEC 05, 2015 Entered By : Date Entered : SEP 19, 2012 Completed By: Date Completed: NOV 20, 2015 Released By : Date Released : DEC 17, 2015 ============================================================================= Packman Mail Message: ===================== No routines included